Application for Appointment at Hope School Position applied for: Scale A Teacher, Permanent Position Personal details: Name: Address: Contact number: Home: Work: Email: Teacher Registration: Are you a New Zealand registered teacher? Yes / No If yes, please include a copy of your registration certificate with your application. Are you a ‘Beginning Teacher’ Yes / No Previous Employment Experience: Position Employer Details of Duties Date Begun Date Ceased Qualifications (Educational or other relevant qualifications): Qualification Date Attained Suitability for position: Please state on a separate sheet or with your C V, what your strengths are and why you think you are suitable for this position. Referees: Provide details of two people who can be contacted to provide references (previous employers preferred): Name (& Position) Address: Phone Day: Phone Night: 1. 2. Medical: Please describe any illness or injury you have had that may affect your ability to effectively carry out the duties and responsibilities of the position. I understand that any false information given in relation to my medical history may result in my loss of entitlement for any compensation from ACC or the Board’s workplace insurer. Convictions against the Law/Unsuitability for the position: Have you ever been convicted of any offence against the law (apart from minor traffic convictions), or otherwise know of any reason why you should not be employed to work with boards of trustees, and/or in the school/education environment? Yes / No If you answered “Yes” , please provide the date and details of the offence, or other reasons, together with any comments you may wish to make. [Please note: (1) You may be asked to provide a copy of the relevant court record(s) obtainable form the Police. (2) Failure to provide correct and true details of any convictions or reason for possible unsuitability will make you liable to dismissal from the employment of Hope School Board of Trustees, should you be the successful applicant.] Confirmation: I solemnly and sincerely declare that, to the best of my knowledge and belief, the information given in this application and my C.V. is true and correct. I understand that this may be verified. “I agree to the references/referees provided to the Hope School Board of Trustees in respect to my application for the position of Scale A Teacher, Permanent Position be used for the purposes of considering my suitability for the position. I also agree that the Board may make further verbal or written inquiry from the referees provided and my previous employer(s).” Under the Privacy Act 1993 you are advised that the personal information you provide will be held within Hope School and will be used for appointment purposes. Should this information be required for statistical or research purposes, individuals will not be identified. By signing this form you are acknowledging that the Board of Trustees may contact your last employer. Applicants signature: Date: Equal Employment Opportunities: You are not obliged to complete the following; however to assist us in monitoring our EEO objectives, this confidential information will be used for statistical purposes only. Gender: Female / Male Date of Birth: Ethnic Identification: Maori/NZ European / Other: Please forward your application to: The Principal Hope School Paton Road Hope R D 1 Richmond NELSON 7081 or Email to : firstname.lastname@example.org Receipt of Application: If you wish to have your C V returned, please include a stamped self-addressed envelope.